Allied General Agency Company
1100 Locust Street, Dept 2002
Des Moines, IA50391-2002
Ph: 888-364-3434 Fax: 866-433-4331
HalfwayHouse General LiabilityApplication
Web site Address
PROPOSED EFFECTIVE DATE:From To 12:01A.M.,StandardTimeattheaddressoftheApplicant
Applicant is:IndividualCorporationPartnershipJoint Venture
Limited Liability CompanyOther (Specify): ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Limits Of Liabilityand Deductible Requested:General Aggregate (other than Products/Completed Operations) / $
Products & Completed Operations Aggregate / $
Personal & Advertising Injury (any one person or organization) / $
Each Occurrence / $
Damage To Premises Rented To You (any one premise) / $
Medical Expense (any one person) / $
Errors and OmissionsEach Claim
Aggregate / $
Sexual and/or Physical Abuse / $25,000/$50,000 (in- cluded)
Other Coverages, Restrictions, and/or Endorsements: / $
Deductible / $
principalsinthefirmdonothaveahealthcarebackground,thenalsoincludetheresumeof theindividualresponsible for hiring, screening and monitoring the work activities of your employees.)
3. Is facilityowned byphysician(s)?...... YesNo
If yes, is physician(s) involved in day-to-day operations?...... YesNo
4. Type of operation:
Birth control, pregnancy orabortion counseling/clinicNon-medical drug and alcohol rehabilitation center Blood testing or communicable disease clinic Outpatient aftercare and support program (AA, Crises center (rape, domesticviolence, etc.) Al-Anon, etc.)
Halfway houseOutpatient counseling or guidance center Healthcare clinic Prisoners work-release or rehabilitation program Homeless shelter Psychiatric institution
Hospice facilityYouth hostel
Mission or settlement house
Describe type of operation and services provided (attachbrochure and/or advertising material if available):
5. Does applicant provide anyoff-premises health care services?...... YesNo
If yes, advise:
6. Operations conducted in the following states:
State: Licensedwith state?...... Yes No License No.:
7. Has license ever been revoked?...... YesNo
If yes, please explain:
8. Name all subsidiarycompanies/locations and others coming under applicant’s control(if none, please state):
9. Has the applicant sold, acquired or discontinued anyoperations in the last five years?...... YesNo
If yes, please explain:
time basis?...... Yes No
11.Physical features of risk:
a. Year built:
b. Construction of building: c. Number of floors: On which floor(s) is applicant located? Square foot area occupied by the applicant:
Central stationLocal alarm
Equipped with smoke detectors?...... YesNo
How many on each floor?
e. Number of fire extinguishers on premises: Number of fire escapes: f. Is smoking allowed on premises?...... Yes No If yes, where is it permitted?
g. Is there a swimming pool orhot tub/spa on premises?...... YesNo
•Number of pools?
•Are the pools fully fenced with self-latching gates?...... YesNo
•Are the rules posted?...... YesNo
•Is there life-safety equipment at poolside?...... YesNo
•Is there a diving board, platform, or slide?...... YesNo
•If yes, height of each:
•Are all swimming pools, wading pools, hot tubs andspas in compliance with the federal Virgin-
ia Graeme Baker Pool and Spa SafetyAct?...... YesNo
h. Was building originally builtfor this type ofoccupancy?...... YesNo
a. Do you have a written Emergency Evacuation Plan?...... YesNo b. Does your plan include advance agreement oftransportation and temporary shelter?...... Yes No c. Are evacuation procedures posted inall parts of your facility?...... Yes No Bilingual?...... Yes No
d. How often are drills conducted?
13.State patients’/residents’ ages—from (youngest) to (oldest)Average age:
14.Physicians on premises, if any,are:
Private practitioners (personal physicians of the resident) Employees of the applicant
Contracted physicians through written contract with applicantIfcontractedphysician,arecertificates(evidence)ofprofessionalliabilityinsurancerequiredandkept on file?...... / Yes / No
15.Do services provided include Infusion Therapy?......
Dialysis?...... Physical therapy?...... Does treatment process involve the administration of methadone or other drugs?...... / Yes Yes Yes Yes / No No No No
16.Are employees authorized to use their personal vehicles to transport residents or patients?...... / Yes / No
17.Are residents/patients placed in applicant’s facilitybycourt order?...... / Yes / No
18.Anyinvolvement in medical detoxification?...... / Yes / No
19.Does facilityaccept prisoners?...... / Yes / No
20.Does facilityaccept teens with a past historyof violence or attempted suicide?...... / Yes / No
If yes, does applicant also require the child’s guardian to be in residence atthesamefacility?...... / Yes / No
23.Is facilitya foster home or foster care facility?...... / Yes / No
24.Does facilityprovide inpatient services or permanent housing for either of the following:
a. Developmentally Disabled—Adultsorchildrenabletocareforthemselvesdespitetheirdisability ormentalretardation.ExamplesofthiscategoryincludeDowns Syndrome, autism and brain injuries.Thiscategorydoesnotincludeindividualswhoseprimarydiagnosisisanemotionalor
mental illness...... YesNo
b. Mentally Disabled—Adultsorchildrenabletocareforthemselves(withsubstantialnumbersable toholdjobs).Behavioriscontrolledthroughmedicationandmonitoredbytheir personal physician. Thiscategorywouldincludeindividualswhoseprimarydiagnosisisanemotionalormentalillness
including but not limited to schizophrenia,psychopathic and sociopathic diagnosis...... YesNo
25.Does the applicant provide bed and board facilities?...... Yes No If yes, number of beds: Length of stay: from (shortest) to (longest) Average:
26.Does the applicant provide outpatient services?...... YesNo
If yes, number of annual outpatient visits:
27.Explain arrangement for medical emergencies (i.e., M.D. on call, transfer arrangements with hospital, etc.):
28.As part of hiring/screeningof newemployees, does applicant:a. / Obtain copies of their professional licenses/certifications?...... / Yes / No
b. / Contact applicants’ references before they are hired?...... / Yes / No
c. / Require that they carry theirown professional liability policy?...... / Yes / No
29.Total number of employees:30.Does applicant have Workers’ Compensation coverage in force?...... / Yes / No
31.Doesapplicanthaveanycontractualagreementswhereinapplicantassumestheliabilityof others?...... / Yes / No
vice(s) applicant provides.
32.Anyother premises or operations exposures not stated in this application?...... YesNo
If yes, attach a complete description and underwriting/rating information.
of applicant’s operation?...... YesNo
If yes, please explain:
to the applicant (Not applicable inMissouri)?...... YesNo
If yes, please explain:
36.Does applicant have other business ventures for which coverage is not requested?...... YesNo
If yes, explain and advise where insured:
37.Schedule of Hazards:Loc. No. / Classification Description / Class. Code / Exposure / Premium Bases
38.Prior Carrier Information:Year: / Year: / Year: / Year: / Year:
39.Loss History—Five Year Period:Indicateallclaimsorlosses(regardlessoffaultandwhetherornotinsured)oroccurrencesthatmaygiveriseto claims for the prior five years. Check if no losses last five years.
Loss / Description of Loss / Amount Paid / Amount
Reserved / Claim Status (Open or Closed)
ThisapplicationdoesnotbindtheapplicantnortheCompanytocompletetheinsurance,butitisagreedthattheinforma- tion contained herein shall be the basis ofthe contract should a policy be issued.
anapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurpose ofmisleading, information concerning any fact material theretocommitsafraudulentinsuranceact,whichisacrimeand subjects such person to criminal and civil penalties.Not applicable in Nebraska, Oregon and Vermont.
NOTICETOCOLORADOAPPLICANTS:Itisunlawful to knowingly provide false, incomplete, or misleading facts or in- formationtoaninsurancecompanyforthepurposeofdefrauding or attempting to defraud the company. Penalties may includeimprisonment,fines,denialofinsurance,andcivildamages.Any insurance company or agent of an insurance companywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsorinformationtoapolicyholderorclaimantfor thepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimant with regard to a settlement or award pay- ablefrominsuranceproceedsshallbereportedtotheColorado DivisionofInsurance within the Department of Regulatory Agencies.
WARNINGTODISTRICTOFCOLUMBIAAPPLICANTS:Itisacrimetoprovidefalseormisleadinginformationto an insurerforthepurposeofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines. In ad- dition,aninsurermaydenyinsurancebenefitsiffalseinformationmateriallyrelatedtoaclaimwasprovided by the appli- cant.
NOTICETOFLORIDAAPPLICANTS:Anypersonwhoknowinglyandwithintentto injure, defraud, or deceive any insur- erfilesastatementofclaimoranapplicationcontainingany false, incomplete, ormisleading information is guilty of a fe- lony in the third degree.
NOTICETOLOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent claim for payment of a lossorbenefitorknowinglypresents false information in an application for insurance is guilty of a crime and may be sub- ject to fines and confinement in prison.
NOTICE TO OHIO APPLICANTS:Any person who knowingly and with intentto defraud any insurance company files an applicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationor conceals for the purpose of misleading,informationconcerninganyfactmaterialtheretocommitsafraudulent insuranceact,whichisacrimeand subjects such person to criminal and civil penalties.
NOTICETOOKLAHOMAAPPLICANTS:Anypersonwhoknowingly,andwithintenttoinjure, defraud or deceive any insurer,makesanyclaimfortheproceedsofaninsurancepolicycontaininganyfalse, incomplete or misleading informa- tion is guilty of a felony.
NOTICETOMAINEAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleading informationto an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICETOMARYLANDAPPLICANTS:Anypersonwhoknowinglyandwillfullypresentsafalseor fraudulent claim for paymentofalossorbenefitorwhoknowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject tofines and confinement in prison.
NOTICETOMINNESOTAAPPLICANTS:Apersonwhofilesaclaimwithintenttodefraudorhelpscommitafraud against an insurer is guilty of a crime.
FRAUDWARNING(ApplicableinTennessee,VirginiaandWashington):Itisacrimetoknowingly provide false, in- completeormisleadinginformationtoan insurance company for the purpose of defrauding the company. Penalties in- clude imprisonment, fines and denial of insurance benefits.
NOTICETORHODEISLANDAPPLICANTS:Anypersonwho knowingly presents a false or fraudulent claim for payment ofalossorbenefitor knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICETONEWYORKAPPLICANTS(Otherthanautomobile):Anypersonwho knowingly and with intent to defraud anyinsurancecompanyorotherpersonfilesanapplication forinsurance or statement of claim containing any materially falseinformation,orconcealsforthepurposeofmisleading,informationconcerningany fact material thereto, commits a fraudulentinsuranceact,whichisacrime,andshall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
PRODUCER’S LICENSE NUMBER:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
As part of our underwriting procedure,a routine inquiry may be made to obtain applicable information concerning character, general reputation, personalcharacteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.